SAH with a ruptured ACOM aneurysm and advised to undergo cerebral DSA with balloon-assisted endovascular coiling
Introduction
This case study is about a 71-year-old female patient with a history of hypertension, diabetes mellitus Type II, and bilateral total knee replacement who was admitted with complaints of severe headache and vomiting. On examination, she was found to have a loss of consciousness for 10 minutes, and a CT scan of the head showed subarachnoid hemorrhage with a ruptured anterior communicating artery aneurysm. The patient was transferred to the ICU and treated with endovascular coiling via the right femoral route. After the procedure, the patient was reviewed by the neurointerventionist, who recommended intra-arterial vasodilation in view of motor weakness and decreased sensorium. The patient underwent the procedure and was managed with supportive care in the ICU. However, the patient’s relative refused further treatment, and the patient was discharged against medical advice.
Clinical Presentation
Mrs. X, a 71-year-old female, was brought to the emergency department with complaints of severe headache and vomiting. She had a history of hypertension, diabetes mellitus Type II, and bilateral total knee replacement. On examination, she was found to have a loss of consciousness for 10 minutes. Her blood pressure was on the higher side at home, and a CT scan of the head showed subarachnoid hemorrhage with a ruptured anterior communicating artery aneurysm.
Investigations
The patient underwent several investigations, including a CT angiography of the brain and neck, which revealed a retroesophageal course of the right subclavian artery, few eccentric calcifications in bilateral CCA without significant stenosis, and anteriorly directed contrast-filled outpouching in the region of ACOM-aneurysm. The patient’s blood investigations showed a TLC of 17,600 and HbA1C of 6.0. A 2D Echo revealed no RWMA, EF-60%, mild concentric LVH, Grade I DD, trace MR/TR, and normal PASP.
Management
The patient was admitted under the Neurology unit for further management with the above-mentioned complaints and was shifted to the ICU, where treatment was started as per standardized protocol. The patient was referred to a neurosurgeon in view of severe headache and NCCT head findings, and his advice was followed accordingly. The patient was also referred to a neurointerventionist in view of SAH with a ruptured ACOM aneurysm and advised to undergo cerebral DSA with balloon-assisted endovascular coiling, which was done under GA on 11.03.2023 by Dr. Nischint Jain. The patient tolerated the procedure well and was shifted back to the ICCU for further management.
The patient was reviewed by the neurointerventionist, who recommended intra-arterial vasodilation in view of motor weakness and decreased sensorium. The procedure was done under MAC on 23.03.2023, and the patient tolerated it well. The patient was managed with supportive care in the form of DVT prophylaxis, stress ulcer prophylaxis, pressure sore prevention, chest, and limb physiotherapy. The patient’s vitals were monitored, ABG was checked, and intake-output charting was done. The patient was on Inj. Norad infusion, Inj Milrinone infusion, and other medications, including antibiotics and pain relievers.
Outcome and Follow-up
The patient’s condition improved after the procedures, but she remained drowsy and unresponsive to verbal commands. The patient’s GC was sick, and the GCS score was E2V1M3. The patient’s vitals showed HR-96/min, BP-138/56 mmHg, and SPO2-94% with room air.
Mrs. X, a 71-year-old female with a history of DM Type II and HTN, presented with severe headache, vomiting, and loss of consciousness. She was diagnosed with SAH with ruptured ACOM aneurysm and cerebral vasospasm. She underwent cerebral DSA and balloon-assisted endovascular coiling and intra-arterial vasodilation. She tolerated the procedures well and was managed in the ICCU with supportive care. However, the patient’s relatives insisted on discharging her against medical advice (DAMA) despite her needing further treatment.
Conclusion:
This case highlights the importance of early recognition and management of SAH with ruptured ACOM aneurysm and cerebral vasospasm. Neurointerventionist and neurosurgeon consultation, along with standardized protocols, are necessary for optimal patient outcomes. The case also underscores the challenges of managing patients when relatives make decisions that are not in the patient’s best interest.